The Medical Records Technician (Clinical Documentation Improvement Specialist) performs quantitative and qualitative review of inpatient and outpatient medical records and encounter forms to ensure diagnoses, conditions, procedures, and evaluation and management services are accurately documented.
This role supports the Health Information Management section at the Kansas City VA Medical Center and helps improve documentation quality, coding accuracy, reimbursement, workload capture, and quality measures. The position also involves provider education, regulatory monitoring, and development of training and documentation improvement activities.
Basic requirements
- U.S. citizenship is required.
- One year of creditable experience demonstrating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health record structure/format.
- Or an associate's degree in Health Information Technology/Health Information Management or a related field with required coursework.
- Or completion of an AHIMA-approved coding program or equivalent intensive coding training program.
- Or an acceptable combination of education and experience.
- Six additional months of creditable experience equivalent to an MRT (Coder) role.
- Required certification: mastery-level certification through AHIMA or AAPC, or a clinical documentation improvement certification.
Qualifying certifications
- CCS
- CCS-P
- RHIT
- RHIA
- CPC
- COC
- CIC
- CDIP
- Certified Clinical Documentation Specialist
GS-9 requirements
- One year of experience equivalent to the GS-8 level, or
- An associate's degree or higher plus three years of CDI experience, or
- Mastery-level certification plus two years of CDI experience, or
- Clinical experience such as RN, MD, or DO plus one year of CDI experience.
Knowledge and skills
- Medical coding and documentation concepts, guidelines, and clinical terminology
- Anatomy, physiology, pathophysiology, and pharmacology
- ICD-CM, ICD-PCS, CPT, and HCPCS coding systems
- CC/MCC, MS-DRG, and POA indicators
- E/M criteria for outpatient coding
- Data analysis and presentation
- Provider communication and education
- Documentation standards and healthcare regulations, including CMS, The Joint Commission, and VA guidelines
Preferred experience
- 2 to 3 years of concurrent or retrospective CDI experience in an inpatient/outpatient acute care facility.
Benefits and perks
- Competitive salary with regular salary increases
- Telework available
- Retention incentive may be authorized for highly qualified candidates
- Federal health, vision, dental, term life, and long-term care insurance
- Traditional federal pension and federal 401(k) with VA matching contributions
- Paid time off: 37 to 50 days annually, including vacation, sick leave, and federal holidays
- Up to 12 weeks of paid parental leave after 12 months of employment
- Child care subsidy may be available for eligible employees
- This is not a virtual position
- Permanent change of station/relocation assistance not authorized
Location
Kansas City, Missouri, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$62,729 - $81,553
Remote work allowed
Yes
Posted
2 weeks ago